ENFORCEMENT

Health Care Fraud and Abuse Program Faces Declining ROI

The federal government’s return on investment (ROI) in the fight against health care fraud continues a steady decline according to the latest numbers reported for the Health Care Fraud and Abuse Control Program (Program). Every year the Department of Health and Human Services and the Department of Justice must jointly report to Congress on the Program’s successes and its expenditures. Those agencies issued a report on accomplishments for fiscal year 2016—the Program’s 20th year—in January. While the successes are significant, the costs are as well.

Here is a rundown on some details revealed in the report:

  • DOJ opened 975 criminal health care fraud investigations and 930 civil health care fraud investigations during FY 2016
  • Prosecutors filed 480 criminal cases and gained convictions for 658 defendants
  • OIG investigations during FY 2016 led to 765 criminal actions and 690 civil actions
  • OIG excluded 3,635 individuals from participating in federal programs
  • $282.1 million in mandatory funding (after $20.6 million in mandatory sequester reductions), and $681.0 million discretionary funding

The bottom line revealed in the report indicates a decline in the ROI for the Program for the third year in a row. For FY 2016 the report reveals an ROI of $5.00 for every dollar spent, for the three-year period 2014-2016. “Because the annual ROI can vary from year to year depending on the number and type of cases that are settled or adjudicated during that year, DOJ and HHS use a three-year rolling average ROI for results contained in the report,” the agencies explain in their report every year.

Here’s how that ROI compares to the ROI reported in the annual reports going back to 2011 (reported for three year period ending in the reported fiscal year):

FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016
$7.20 $7.90 $8.10 $7.70 $6.10 $5.00
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